GW1-2022-10170_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Chris Morgan 14.WATERZONEs �. x::s
FROM TO DESCRIPTION
Well Contractor Name RECEIVED 1 ft. �` ft.
3572-A 7
NOV V 1 0 2022 15 AUTER'CASING formulhtased`w
NC Well Contractor Certification Number ells OIt:I1NER'tf'a' hcalile
Morgan Well & Pump, INC FROM T011 DIAMETER THICKNESS MATERIAL
{na9a�f�lximBel[40 unA O ft. ft. in.
Company Name ';�oMNER.0 oING.OR-.TUB DDG_IAMET'gbEth R erufal'elosed-loo`N .
TffiCKNESS MATERIAL
LL
2.Well Construction Permit#: ' J�D[� ft. ft. in
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.)
ft. ft.
in.
3.Well Use(check well use): r ,,
17:SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
71 Agricultural �Zidc.tial
icipal/Public
i Geothermal(Heating/Cooling Supply) Water Supply(single)
IndustriaUCommercial Residential Water Supply(shared) .;
18:GR017T
hri ation FROM TO MMATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO fL bentonite poured
Monitoring EIRecovery
Injection Well: ft. ft.
Aquifer Recharge [3Groundwater Remediation >-
19:$A1VD/GRAVEL TACK'if a livable, =
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stonnwater Drainage
Experimental Technology oSubsidence Control 20:DRILLIlVG`LOG aftacH`addthoh
ft. ft.
Geothermal(Closed Loop) Tracer "al sheets ifnecess `");'
FROM TO DESCRIPTTON(color,hardness,soil/rocktyp
e, rain size,etc.
J Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) d ft. ft C
60
4.Date Well(s)Completed: 10 et/-n 2- Well D# ft• y ft. 16A
Sa.Well Location: ft. u5 fL
gpAey . fL
Facility/Owner Name �( C( /A�' Facility ID#(if applicable)
3d3 Cl�ctytvl�c,CA �HOIC�T/V✓ ft. ft.
Physical Address,City,and Zip
21.1 REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient), 22.Certification:
35 3i45 N --91 . 115b W a AL
L
signature ofterti0d Well Contractor i Date
6.Is(are)the well(s)oPermanent or 1ITemporary
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or X;No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J a (ft-) 24a. For All Wells: Submit thus form within 30 days of completion of well
For multiple wells list all depths if eti erent(example-3@n20L0'and 2@I00� construction to the following:
10.Static water level below top of casing: Z (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service!Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1�$ (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
rotary above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 16 Method of test: ►>r 24c.For Water Supply&Ini lction Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
chlorine got completion of well construction' to the county health department of the county
13b.Disinfection type: Amount:
where constructed.